What is the best treatment approach for a patient with chronic insomnia, characterized by difficulty falling asleep and staying asleep, with a sleep schedule of 10:30 pm to 3 am, and a negative depression screen?

Treatment of Chronic Insomnia

Cognitive Behavioral Therapy for Insomnia (CBT-I) is the required first-line treatment for this patient with chronic insomnia, delivered over 4-8 sessions, incorporating sleep restriction therapy, stimulus control, and cognitive restructuring. 1, 2

Why CBT-I Must Be First-Line

• The American Academy of Sleep Medicine provides a STRONG recommendation that all adults with chronic insomnia receive CBT-I as initial treatment before any pharmacological intervention 1, 2
• CBT-I produces clinically meaningful improvements sustained for up to 2 years, unlike medications which show degradation of benefit after discontinuation 2, 3
• Meta-analysis demonstrates CBT-I reduces sleep onset latency by 19 minutes, wake after sleep onset by 26 minutes, and improves sleep efficiency by 9.91% 3
• Prescribing hypnotics as first-line treatment violates guideline recommendations and deprives patients of more effective, durable therapy 2

Core CBT-I Components for This Patient

Sleep Restriction Therapy (Critical for This Case)

• Calculate this patient's current total sleep time from sleep logs (likely ~4-5 hours given the pattern) 1
• Restrict time in bed to match actual sleep time (minimum 5 hours), not the 7+ hours currently spent in bed 1
• Set consistent bedtime (later than 10:30 pm initially) and wake time to achieve >85% sleep efficiency 1
• Adjust time in bed weekly: increase by 15-20 minutes if sleep efficiency >85-90%, decrease by 15-20 minutes if <80% 1
• Caution: Avoid sleep restriction in patients with seizure disorder or bipolar disorder 4

Stimulus Control (Addresses the Maladaptive Behaviors)

• Go to bed only when sleepy, not at a predetermined time like 10:30 pm 1
• Use bed only for sleep—no reading or watching TV in bed (this patient's current 3 am behavior is perpetuating insomnia) 1
• If unable to fall asleep within approximately 20 minutes, leave the bed and engage in relaxing activity until drowsy, then return—repeat as necessary 1
• Avoid clock-watching; remove visible clocks from bedroom 1
• Maintain consistent wake time regardless of sleep quality 1

Cognitive Therapy

• Address this patient's likely maladaptive beliefs: "I must get 8 hours," "I can't function without perfect sleep," "I should stay in bed trying to sleep" 1
• Challenge catastrophic thinking about consequences of poor sleep 1, 5

Sleep Hygiene (Adjunct Only)

• Sleep hygiene alone is insufficient and should NOT be used as single-component therapy 1, 2
• Include as part of multicomponent CBT-I: avoid caffeine after noon, no alcohol near bedtime, optimize sleep environment 4

Implementation Strategy

• In-person, therapist-led CBT-I is most beneficial; digital CBT-I is effective when in-person unavailable 2
• Treatment typically requires 4-8 sessions over 6 weeks 2
• Counsel patient that improvements are gradual but sustained—initial mild sleepiness and fatigue typically resolve quickly 4
• Sleep restriction may cause temporary increased daytime sleepiness but improves sleep consolidation 1, 5

When Pharmacotherapy May Be Considered

Only after CBT-I has been attempted or when CBT-I is unavailable should pharmacotherapy be considered 2

First-Line Medication Options (If CBT-I Insufficient)

• For combined sleep onset and maintenance insomnia (this patient's pattern): eszopiclone 2-3 mg or zolpidem 10 mg 4
• Ramelteon 8 mg for sleep onset difficulty 4
• Low-dose doxepin 3-6 mg specifically for sleep maintenance insomnia 4

Medications to Avoid

• Over-the-counter antihistamines (diphenhydramine) are NOT recommended due to lack of efficacy data, daytime sedation, and delirium risk 4
• Trazodone is NOT recommended by the American Academy of Sleep Medicine 4
• Long-acting benzodiazepines carry increased risks without clear benefit 4
• Sleep hygiene education alone or melatonin have insufficient evidence 1, 2

Critical Safety Considerations

• All hypnotics carry risks: driving impairment, complex sleep behaviors (sleep-walking, sleep-driving), falls, fractures, cognitive impairment 4
• Benzodiazepines should be avoided when possible due to dependence, withdrawal, cognitive impairment, and fall risk 4
• Short-term hypnotic treatment (if used) must be supplemented with CBT-I, not used as replacement 4
• Use lowest effective dose for shortest duration possible 4

Common Pitfalls to Avoid

• Do NOT prescribe medications before attempting CBT-I—this is the most common error 2
• Do NOT allow patient to continue reading/watching TV in bed at 3 am—this reinforces wakefulness association 1
• Do NOT rely on sleep hygiene education alone—it lacks efficacy as single intervention 1
• Do NOT let patient stay in bed "trying to sleep" for hours—this worsens conditioned arousal 1
• Avoid telling patient to go to bed at fixed time (10:30 pm)—should only go to bed when sleepy 1

Assessment Before Treatment

• Screen for underlying sleep disorders: sleep apnea (snoring, witnessed apneas, obesity), restless legs syndrome (uncomfortable leg sensations), circadian rhythm disorders 4
• Depression screen is already negative in this case